Provider Demographics
NPI:1083933873
Name:HEIDLEBAUGH, MICHAEL ALAN (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ALAN
Last Name:HEIDLEBAUGH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2990 GREENFIELD RD
Mailing Address - Street 2:
Mailing Address - City:BERKLEY
Mailing Address - State:MI
Mailing Address - Zip Code:48072-1160
Mailing Address - Country:US
Mailing Address - Phone:248-797-6709
Mailing Address - Fax:
Practice Address - Street 1:2990 GREENFIELD RD
Practice Address - Street 2:
Practice Address - City:BERKLEY
Practice Address - State:MI
Practice Address - Zip Code:48072-1160
Practice Address - Country:US
Practice Address - Phone:248-797-6709
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-19
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ4766207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine